Provider Demographics
NPI:1720404932
Name:LIGHTHOUSE BEHAVIORAL WELLNESS CENTERS
Entity Type:Organization
Organization Name:LIGHTHOUSE BEHAVIORAL WELLNESS CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPUTY EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEANA
Authorized Official - Middle Name:
Authorized Official - Last Name:THARP
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:580-319-7305
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73402-0189
Mailing Address - Country:US
Mailing Address - Phone:580-223-5070
Mailing Address - Fax:580-223-5617
Practice Address - Street 1:109 S WILLOW ST
Practice Address - Street 2:
Practice Address - City:PAULS VALLEY
Practice Address - State:OK
Practice Address - Zip Code:73075-3833
Practice Address - Country:US
Practice Address - Phone:405-238-7311
Practice Address - Fax:405-238-3530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-12
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1007288302084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100728830Medicaid
OKMHSSWMedicare UPIN